Journal of Drug Abuse

ISSN: 2471-853X

Open Access Research Article

Does the Assertiveness Skills Training Program Affect the

Development of Sobering Behavior Among Drug Abusers? A Quasi-
Experimental Study
Amal I Khalil1*, Eman A Shoker2, Safaa E Shatlah3
1Department of Health Sciences, King Saud bin Abdelaziz University for Health Sciences, Jeddah, Saudi Arabia
2Department of Family and Community Health Nursing, Menoufia University, Menofia Governorate, Egypt
3Department of Psychiatric and Mental Health Nursing, Menoufia University, Menofia Governorate, Egypt

Abstract
Background: Losing control over drug use and using excessive amounts of drugs without thinking
about the repercussions is known as substance misuse. The ability to articulate thoughts and feelings
in a certain way can be enhanced via the use of developed and created assertiveness skills training
programs, which will significantly improve drug users' capacity to say no and make the right choices.

Aim: Investigating the effectiveness of assertiveness skills training programs in developing sober
behavior among drug abusers.

Methods: One group underwent a pre-and post-test under a quasi-experimental design. A purposeful
sample of 90 male patients with substance use problems participated in the study at the psychiatric
and addiction treatment hospital in Meet-Khalaf, which is associated with the Ministry of Health in
the Menoufia Governorate, Egypt. Three valid and reliable instruments were used to achieve the
objectives of the current study, including demographic and personal data, assertion behavior, Zagers’s
addiction potential scale and relationship inventory.

Results: There was a highly statistically significant improvement in the level of assertiveness skills in
drug use post-intervention than before at p ≤ 0.001, and there was a highly statistically significant
improvement in all dimensions of assertion in drug use. Also, there was a highly statistically significant
reduction in the potential for addiction among the participants post-intervention compared to pre-
intervention at P ≤ 0.01.

Conclusion and recommendations: The assertiveness training in this study positively affected the
reduction of drug use propensity, leading to meaningful improvement in the level of assertiveness
skills of the studied participants post-intervention. Therefore, it is recommended that assertiveness

Received: 21-September-2022 Manuscript No: IPJDA-22-14409

Editorassigned: 23-September-2022 PreQC No: IPJDA-22-14409 (PQ)
Reviewed: 07-October-2022 QC No: IPJDA-22-14409
Revised: 02-February-2023 Manuscript No: IPJDA-22-14409 (R);
Published: 09-February-2023 DOI: 10.36648/2471-853X.23.9.07

Corresponding author: Amal I Khalil, Department of Health Sciences, King Saud bin Abdelaziz University for Health Sciences,
Jeddah, Saudi Arabia; E-mail: khalila@ksau-hs.edu.sa
Citation: Khalil AI, Shoker EA, Shatlah SE (2023) Does the Assertiveness Skills Training Program Affect the Development of Sobering
Behavior Among Drug Abusers? A Quasi-Experimental Study. J Drug Abuse. 9:07.
Copyright: © 2023 Khalil AI, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are
credited.

© Under License of Creative Commons Attribution 4.0 License

This article is available in: https://www.primescholars.com/drug-abuse.html Volume 09 • Issue 02 • 07
Page 2
Khalil AI, et al.

skills training programs must be disseminated to all psychiatric hospitals and addiction treatment
centers. Assertiveness training for nurses should be continuous, on a regular basis in order to
empower them with the skills necessary to detect, prevent, and treat drug abuse as early as possible.
The communities that make an effort to come together in the fight against drugs are sure to make an
impact on the prevention of drug abuse. There are many places to establish these prevention
programs, including schools, churches and community based clubs.

Keywords: Drugs; Abuse; Assertiveness; Sobering; Program

essential to regularly update the prevalence studies on mental

INTRODUCTION
Substance abuse can be described as losing control over
substance consumption, involving an extreme amount of drug
use without considering the negative consequences. The
drugs mainly affect the reward system in the brain by sending
2 to 10 times more dopamine than what is usually produced
in the receptors and synapses. Consequently, a substance
abuser will not experience pleasure with the normal amount
of dopamine and the abuser’s body will be dependent on the
illegal substances, which is a severe form of substance use
disorder characterized by chronic drug seeking and drug use
resulting in dysregulation of the reward system [1].
Ten percent of Egyptians use drugs, 27.5% are females, and
24% are drivers who rely on drugs to stay awake. Children or
young people between the ages of 12 and 19 are
disproportionately affected by drug use. Around 38% do so
for experimentation and 25% do so for creativity. Peer
pressure is another factor, with 36.6% abusing drugs for social
acceptance and 29% because they are dared by others [2]. To
our knowledge, there were a few pieces of research that were
done in the field of psychosocial interventions, including
assertiveness training as a part of rehabilitation for drug
abusers to develop sobriety behaviors. Research identifies
several risk factors that contribute to substance abuse and
dependence, which are mostly curiosity, peer pressure,
loneliness and a dysfunctional family system. According to the
psychosocial developmental stage, the adolescent age of the
substance abuser is among the factors that interfere with the
initiation of drug abuse as adolescents in this stage go
through experiencing new and different roles, activities and
behaviors with a full sense of curiosity seeking the formation
of their identities. In the same line, found that the adolescent
age of first use ranges from 13.2 years for alcohol to 15.2
years for cocaine, which confirms that psychosocial
development of identity as a virtue occurs between the ages
of 12 to 18 years old. Furthermore, many substance abusers
begin abusing in their early adulthood, making it difficult for
them to maintain positive relationships with others and to
feel lonely. Furthermore, peer pressure plays an important
role in this stage where an adolescent gets affected by their
peers and tries the same things to keep up their relationships
[3].
Significant of the Study
Over the last few decades, substance abuse has become one
of the world's most serious and rapidly growing problems. It is
illnesses, including substance use disorders, so that
prevention and management plans can be adjusted
accordingly. The escalating substance abuse and addiction
issues emulating from Egypt are fast-becoming well-known
issues, which can no longer be swept under the rug by
Egyptian officials and decision-makers. Although Egyptian
drug addicts are on the rise, recent reports confirm there is a
rise in those seeking treatment [4]. The percentage of
patients who had been treated previously and readmitted
again was 82%, which indicates an increased number of
relapses among drug users, which is more than new detected
situations. In addition, despite the increasing efforts of the
Egyptian government, which are aligned with preventing and
treating drug abuse, there is growing evidence indicating that
drug users are increasing [5]. Additionally, there are, however,
many rehab centers in Egypt that are illegal, unqualified and
unsupervised by the government. To the best of our
knowledge, the drug users treated in governmental addiction
hospitals didn’t wait to complete the rehabilitation program
during their hospitalization. Besides, a few research studies
were conducted in Egypt to assess the social and assertive
skills of drug users. Additionally, the results of previous
studies confirmed that training social skills contributed
effectively to reducing the number of patients admitted and
preventing relapse. Therefore, we looked into investigating
the effectiveness of the assertiveness training program in
developing assertive behavior among drug users at the
psychiatric and addiction treatment hospital in Meet-Khalaf
affiliated with the Egyptian general secretariat of mental
health, Menoufia Governorate, Egypt [6].
Aim of the Study
An evaluation of the effectiveness of assertiveness skills
training programs in developing sobering behavior among
drug abusers. More specifically:
• Assess participants’ assertiveness behaviors pre/post
interventions.
• Assess participants' quality of their relationships and the
support received from the key relationships in life to check
their eligibility to participate in the study. (Pre only).
• Find the association between the participants’
demographic background and their social skills in pre/post
assessment.

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Research questions
• What is the participant's level of knowledge concerning
assertive behavior?
• What is their relationship quality and the support they
receive from their key relationships?
• Is there any association between the participants’
demographic background and their social skills?
Hypothesis
The study tried to test the following two hypotheses:
• Teaching assertive programming skills is effective in
developing sobering behavior among study participants.
• Teaching assertive programming skills is not effective in
developing sobering behavior among study participants.
MATERIALS AND METHODS
Study Design
The research design for this study is a quasi-experimental
one-group with a pre and post-test [7].
Study Area/Setting
The study was conducted in the psychiatric and addiction
treatment hospital in Meet-Khalaf affiliated with the ministry
of health at Menoufia Governorate, Egypt. The hospital is
located in the Meet Khalaf village, Menoufia Governorate and
has 300 beds dealing for both genders [8]. The hospital has 25
beds reserved for emergency cases that are severe and
advanced in addition to the outpatient department. Due to
the increasing number of patients, the priority of admission is
usually given to severe urgent cases. All admitted patients go
through many stages starting with detoxification, which is
mandatory, while other stages of rehabilitation are optional.
The hospital received patients either through the secure ward
or they have referred by the anti-drugs directorate or police.
On the other hand, some patients admit themselves or are
admitted by their families [9].
Study Subjects and Sample Size Calculation
The study population was a non-probability sample
(convenient technique) of male drug addicts who were
referred to the psychiatric and addiction treatment hospital in
Meet-Khalaf affiliated to the ministry of health in Menoufia
Governorate, Egypt during a period of data collection. The
following inclusion criteria were used to choose the
participants: Being at least 18 years old, having a history of
drug addiction as determined by a nurse or doctor based on a
drug test and being past the point of recovery from
withdrawal symptoms having no psychotic symptoms, giving
informed consent, being willing to engage, scoring low or
below average on Pierce's social relationship inventory and
expressing informed permission. The individuals were
questioned after the required coordination was completed
and approval was secured from the hospital management
Khalil AI, et al.
[10]. Once the necessary coordination was made
and permission was obtained from the Manager of the
hospital, the study's participants were asked to sign up
voluntarily. About 5 addicts refused to participate in the data
collection, 4 patients left the study after finishing the study
instruments, and 9 addicts had their data missing, thus
they were not included in the analysis. A non-
probability convenient sampling technique was employed
to select a group of drug abusers who were admitted to the
hospital setting and agreed to participate in the study out
of all patients who met the inclusion criteria and
consented to do so [11]. 90 male patients with
substance use disorders made up the final sample, which
was chosen on purpose. All patients who met the inclusion
criteria and agreed to take part in the study were
contacted. A purposeful sample of 90 male patients with
substance use problems made up the final sample (Figure 1).
Figure 1: Sample size calculations (Consort study flow
diagram).
Data Collection Instruments and Measurements
Personal information: Sheet which enquires the
subjects about their level of education, job, age, and duration
of drug dependency, did they attend any workshops before,
type of drug dependency, etc. [12].
The Zager’s addiction: Potential scale is a self-reported
tool for assessing an individual's sensitivity or
vulnerability to Substance Abuse (SA), whether they are
actively abusing or not. The scale was created by Wade and
Boucher and efforts have been made to ascertain its
reliability in Iran. Based on the social and psychological
background of Iranian society, Zarger developed the Iranian
Addiction Potential Scale (IAPS). The scale consists of 36
items, each of which is scored on a four-point scale (being
absolutely disagreed to 3 being completely agreed), as
well as five lie detector statements questions 12, 13, 15,
21, and 33 that are reverse-scored. The IAPS evaluates two
factors: the first is active potential which measures antisocial
conduct, drug usage propensity, positive attitudes about
substances, and excitement (28 items). The second factor is
the negative potential (9 items) is related to lack of self-
assertion and depression. The total points of each question
on the questionnaire, ranging from 1 to 118 (excluding
the lie detector scale), must be added together. The
likelihood of the respondent becoming addicted increases
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with higher scores and vice versa. Prior studies found that the
scale has a good level of internal consistency (Cronbach >0.90,
for active potential >0.91 and for passive potential >0.75).
Good psychometric qualities for the entire scale were also
observed by Zarger and Ghaffari (Cronbach >0.90; 0.91 and
0.75 for active and passive potential, respectively). According
to a study, the active and passive potentials for the entire
scale have Cronbach alpha values of 0.87, 0.85 and 0.70,
respectively [13].
Assertion Questionnaire in Drug use (AQ-D): It was utilized to
evaluate assertiveness in refusing drugs. The questionnaire
has 40 items and six subscales, including: General
assertiveness (items 5,11,17,23,30,35); good feedback (items
1,7,13,19,26,32); negative feedback (items 2,8,14,20,27,33);
drugs (items 3,9,15,21,28,37); authority (items
4,10,16,22,29,38) and heterosexual (items 4,10,16,22,29,
(items 6,12,18,24,25,31,34,36,39,40). When working with
substance abusers, where assertiveness or social skills training
is a key intervention, this metric is seen to be especially
helpful. It was scored on a scale of 1 to 4 with 1 being the
least complimentary to me (always descriptive of me). The
sum of the 40 item scores represented the final score. The
lowest and highest scores were 40 and 160 respectively. The
remaining content sections (each with six items) varied from
10 to 40 on the general subscale [14].
Quality of Relationship Inventory (QRI): It is a self-
assessment questionnaire developed by Pierce and Sarason to
measure the support received from key relationships in life.
This inventory consists of 25 questions with three subscales of
social support, depth of relationships, and conflicting
relationships: support (7 items), depth (6 items) and conflict
(12 items). The support subscale assesses the perceived
availability of social support from specific relationships. While
the depth subscale measures the extent to which the
relationship is perceived as positive and important. In
addition to the conflict subscale, which was used to
determine whether the relationships were conflictual or
ambivalent, the following variables were considered. Each
item is assessed on a 4-point likert scale ranging from 1 (not
at all) to 4 (very much) [15]. Scores are obtained through their
subscales, by calculating the means of the items that
constitute each subscale. Higher scores in the support and
depth dimensions mean better quality of the relationship,
whereas higher scores in the conflict dimension are
interpreted in terms of lower quality of the relationship.
Pierce and Sarason reported the reliability of the tool as
Cronbach's alpha of the subscales of social support, depth of
relationship, and conflicting relationships as 0.83, 0.88 and
0.86, respectively. The questionnaire was translated into
Arabic and a back translation will be used to verify the validity
of the Arabic version, and then reliability will be reported
after piloting [16].
Validity and reliability of the scale: To ensure the content
validity of the scales, a back translation was done from
Persian to English The back translation was used to verify the
used tool as it will be translated into the Arabic language to
ensure its easy understanding by the participants whose
Khalil AI, et al.
mother tongue is already the Arabic language. After that, a
peer review for the Arabic version was done by distributing it
to a panel of experts in psychiatric nursing, psychology and
social sciences. The reliability of the tool is ensured through
conducting a pilot study, which might reflect the clarity of the
statements, the needed time to fulfill the tools and any
ambiguities in understanding and comprehension [17].
Data Collection Procedure
Permission to conduct the study was attained from the
directors of the psychiatric and addiction treatment hospital
in Meet-Khalaf, Menoufia, Egypt. Informed consent was
obtained from each participant after receiving detailed
information about the purpose of the study. The study was
carried out from the beginning of December 2021 to the end
of June 2022 [18].
Assertiveness Training Program Description
The assertiveness training program is a type of behavior
therapy that teaches patients how to assert their rights and
empower themselves to manage various social relationships.
The primary goals were to teach patients the necessary skills
for defending their rights to say "No" to drug abuser peers,
communicating their needs and opinions while remaining
respectful of others and assisting patients in initiating and
maintaining communication with others [19].
General Objectives of the Program
By the end of the training program the patients will be
expected to:
• Learn communication skills that are necessary for initiating
and maintaining communication with others.
• Utilize self-assertive behaviors to solve their social
problems.
• Apply stress management techniques and anger control
strategies when handling stressful life situations.
Data collection proceeded in 3 main phases as the followings:
1st Phase: Introduction and Informed Consent
Following study approval, all participants who met the
inclusion criteria and were hospitalized at the psychiatric and
addiction treatment hospital in Meet-Khalaf affiliated with the
ministry of health in Menoufia Governorate, Egypt, were
contacted and asked to complete a demographics
questionnaire sheet. The participants were given an overview
of the study and asked to sign an informed consent form. The
participants were then asked to complete the pre-assessment
inventory and the assertiveness scale. Before completing the
quality of relationship inventory, participants were asked to
consider some of their friends (including those with positive
and negative influences on their lives).
2nd phase: Implementations of the Program
Preparation of the content: The program's content was
created using other related literature. The program strategy
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(timetable, teaching methods, and participant assignments
based on each skill given) were all part of the planning phase.
The program covered topics such as assertiveness, problem-
solving, stress management, and giving and receiving praise
[20].
Preparing the patients: The researchers established a
protocol for preparing patients to participate in the study
during an introductory phase. Establishing rapport with
patients is accomplished by assuring them of their
confidentiality and anonymity and researchers facilitate a
sense of warmth and security.
Conducting Pre-Test Assessment and Data Collection
Before the program began, all participants were required to
complete all pre-study tools, which included the relationship
inventory, the assertion questionnaire on drug use, and the
Zargar scale. The researchers collected the pre-test during the
morning each Tuesday and Thursday from 10 AM to 2 AM for
three months (from December 2021 to February 2022).
Before the sessions began, the participants were divided into
smaller groups (eight groups) of 11-12 people each for more
effective training and practice. A schedule is created based on
the schedule of the hospital patients. During the course
(seven sessions of two hours each, divided into two groups
per day), the participants were instructed to attend a social
skills training course conducted in the hospital based on the
schedule provided by the author. Each meeting takes place
twice weekly at the same time and in the same location over a
period of four months (two days in one week) from March
to June 2022.
Table 1: Contents and objectives of the training session.
Session
Session 1 Self-awareness skill
Session 2 Anger and emotional control skills
Khalil AI, et al.
Implementation Phase
• The researchers presented all of the training materials to
all groups using various instructional methods such as
lectures in the form of PowerPoint presentations,
brainstorming, demonstrations and giving examples. Also,
media, videos, and brochures were used. Furthermore,
the materials were distributed to all participants in the
form of brochures.
• Each group received instruction in life and social skills such
as assertiveness, anger management and how to
communicate and develop positive relationships with
others during these sessions. Problem-solving, stress
management and giving and receiving praise are also
important skills. The final 10 minutes of each session were
set aside for a summary, which focused on the skills
learned during that session.
• The researchers used a variety of training methods,
including group discussions, modelling, role-playing,
feedback and presenting social situations from patients'
memories.
• Participants were asked to practice their skills by playing
the role during the training sessions. Meanwhile,
members of each group were instructed to practice the
skills in their daily living activities within the hospital
setting or elsewhere to strengthen them during training
sessions.
• The sessions' content and purpose were determined using
WHO and UNICEF guidelines (Table 1).
Topic Objectives
Defining self-awareness, personal zones,
and psychological aspects of human beings
in a simple way.
Expressing stresses and pressures deep
inside explaining the concept of emotional
intelligence and its effect on an individual in a
simple way.
Explaining the concept of self-dignity and its
use in the way of realizing goals.
Naming different ways of self-awareness.
Knowing the negative emotions,
Learning about one’s specifications in the
situations that cause anger,
Knowing the causes of anger,
Naming the situations that cause anger,
Naming the specifications of those who can
control their anger,
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Khalil AI, et al.

Naming different ways to control one’s anger

in different situations,

Explaining the concept of determinism and

its effect on controlling anger.

Session3 Stress control skills Defining stress, perceiving personal

differences in dealing with stressors,

Expressing effects of stress on.

Human and the relationship between stress

and psychophysical diseases,

Explaining the relationship Between stress

and emotion, combined anger control and
stress coping skills,

Naming short/long-term methods to control

stress.

Session 4 Problem-solving and decision making Defining the concepts of problem and
problem-solving.

Making familiarity with the relationship

between problem-solving and emotional self-
awareness,

Explaining the concept of brainstorming and

the way of examining solutions.

Developing one's skills in choosing,

implementing, revising, and finding the best
solutions.

Making familiarity with the specifications of

the people unable to make a decision (Styles
of communications).

Listing specifications of a good decision,

Explaining the stages of making,

implementing, and revising a proper
decision;

Learning about the specifications of the

people who cannot solve problems

Session 5 Improvement of interpersonal relationships Defining relationships,

Explaining proper relationship skills,

Explaining the importance of proper

relationships,

Naming the effect of interpersonal

relationships,

Teaching how to create an effective

relationship.

Naming the methods to improve the quality

of relationships with others

Session 6 Practicing empathy and courage Defining empathy and how to have an
empathetic relationship with example.

Explaining the importance of sympathetic

relationships with others.

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Khalil AI, et al.

What are the differences between empathy

and Sympathy?

Defining skills of self-expression,

determinism, and courage to deal with life
problems and hardships.

Session 7 Summarizing and reviewing the course All the topics of the past six sessions were
summarized. The training was evaluated,
and the participants' feedback and questions
were answered.

3rd Phase: Closing and post-assessment measurement

RESULTS
The researchers thanked all participants for attending and
completing the intervention during this phase. The Table 2 revealed that the studied patients were under the
participants were then asked to complete the (post-test) after age of 40 years; 67.8% were from cities; 40% were married,
completing the intervention, using research instruments two, and only 15.5% were divorced. The majority (75.6%) of
three and four to evaluate the intervention's effectiveness. the participants were employed. In terms of educational level,
less than half (42.2%) of the studied group had a higher
educational level, while 31.2% completed secondary school,
Data Management and Analysis Plan
and (36.6%) were literate (read and write). Only 28.9% of
The latest version of the SPSS software was used to analyze the studied group had attended workshops on addiction
the data. Descriptive statistics, including mean and standard program intervention, despite the fact that more than half of
deviation, were used to describe the variables of the the sample had sufficient income and 66.7% had a positive
inventory and scale. A paired t-test was used to compare the family history of addiction (Figure 2).
changes in the mean score of the inventory and the scale of
the participants' pre/post interventions. The test was used to
find the association between demographic characteristics of
the participants and their mean scores pre and post
interventions, and the significance level was calculated at P ≥
0.05.
Table 2: Distribution of studied participants related to their socio-demographic characteristics (N=90).

Studied variables Number Percentage

Age Less than 40 79 87.78

More than 40 11 12.22

Place of living Rural 29 32.2

Urban 61 67.8

Marital status Single 33 36.7

Married 36 40

Widowed 7 7.8

Divorced 14 15.5

Occupation Worked 68 75.6

Not worked 22 24.4

Educational level High education 38 42.2

Secondary 28 31.2

Read and write 13 14.4

Illiterate 11 12.2

Attending any workshop before Yes 26 28.9

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Khalil AI, et al.

No 64 71.1

Income Sufficient 48 53.3

Insufficient 42 46.7

Family history of addiction Positive 60 66.7

Negative 30 33.3

Table 3 illustrated that there is a highly statistically

significant reduction in the potential for addiction
among the participants post-intervention than pre-
intervention at P˂0.01.

Figure 2: Showed that an equal number (31.11%) of

the participants were using heroin and multiple drugs,
followed by (18.89%, 11.11%) and 7.78%) using hashish,
tramadol and opioids, respectively.

Table 3: Mean and SD of the quality of relationships among studied patients on pre/post interventions (N=90).

Items Type Mean Standard Degree of T-test P-value

deviation freedom

Active potential Pre 63.52 9.82 178 40.67 0

for addiction
Post 39.36 5.27

Passive potential Pre 18.78 3.46 178 52.55 0

for addiction
Post 8.84 1.59

The total Pre 82.4 11.33 178 25.13 0

potential for
addiction Post 48.1 6.27

Table 4 clarified that the increase in the mean score of relationships among participants post-intervention was greater
quality of relationship in all aspects of social than pre-intervention at P˂0.01.
support, depth of relationship, and total score of quality

Table 4: Mean and SD of the quality of relationships among studied patients on pre/post interventions (N=90).
Standard Degree of
Items Type Mean T-test P-value
deviation freedom

Social support Pre 12.08 3.64 178 17.79 0

Post 21.14 3.19

Conflicting Pre 19.62 6.49 178 12.27 0

relationships
Post 41.98 4.06

Depth of Pre 10.4 2.94 178 43.63 0

relationships
Post 19.91 2.55

Total quality of Pre 42.1 8.62 178 16.11 0

relationships
Post 83.03 7.7

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Khalil AI, et al.

This Table 5 reflected that there is a highly statistically drug use and total score among the participants post-
significant improvement in all dimensions of assertion in intervention than pre-intervention at P˂0.01.

Table 5: Difference between pre and post assertion program in drug use of the studied patients (N=90).

Items Type Mean Standard Degree of T-test P-value

deviation freedom
Positive Pre 11.68 2.83 178 25.36 0
feedback
Post 21.4 2.28
Negative Pre 19.64 2.27 30.05 0
feedback
Post 10.26 1.91
Drug Pre 11.34 2.09 178 37.84 0
Post 21.73 1.54
Authority Pre 9.6 1.89 178 28.47 0
Post 19.57 2.73
Heterosexual Pre 10.27 1.89 178 32.49 0
Post 20.81 2.43
General Pre 16.94 4.99 178 25.02 0
assertiveness
Post 34.06 4.14
The total Pre 79.48 8.27 178 39.16 0
assertion in drug
use Post 127.82 8.29

Figure 3 revealed that there was a highly statistically
significant improvement in both the quality of the
relationship and the assertion of drug use among the
studied patients after the intervention compared to before
the intervention. Also, there was a highly statistically
significant reduction in the potential for addiction among the
studied patients’ post-intervention compared to pre-
intervention.
Table 6 shows at P˂0.01 there was a statistically significant
negative correlation between assertion in drug use,
relationship quality, and potential for addiction post-
intervention. This means that when the patients have high
assertiveness skills and quality of the relationship, the
potential for addiction will be decreased.

Figure 3: The difference between the total mean score of

studied groups’ potential for addiction, quality of relationships,
and assertion in drug use pre and post-intervention (N=90).

Table 6: Spearman’s correlation between the potential for addiction, quality of relationships, and assertion in drug use among
the studied patients' pre and post-intervention (N=90).

Variables Pre-total Post-total Pre-total Post-total Pre-quality of Post-quality

potential for potential for assertion in assertion in relationship of
addiction addiction drug use drug use relationship

Pre-total r 1 0.63 -0.213 -0.197 0.225 -0.012

potential for
addiction P-value 0 0.043 0.063 0.033 0.91

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Khalil AI, et al.

Post-total r 0.63 1 -0.302 -0.362 -0.194 0.058

potential for
addiction P-value 0 0.004 0 0.067 0.585

Pre-total r -0.213 -0.302 1 0.729 0.302 0.086

assertion in
drug use P-value 0.043 0.004 0 0.004 0.419

Post-total r -0.197 -0.36 0.729 1 0.19 0.2

assertion in
drug use P-value 0.063 0 0 0.073 0.058

Pre-quality of r -0.225 -0.194 0.302 0.19 1 0.605

relationship
P-value 0.033 0.067 0.004 0.073 0

Post-quality of r -0.012 0.058 0.086 0.2 0.605 1

relationship
P-value 0.91 0.585 0.419 0.058 0

Table 7 shows there was a highly statistically significant relationship between age over 4 0, widowed, read a nd write,
relationship between age less than 40, the residence of the and illiterate and potential for addiction post-intervention.
participants, marital status, occupation, income, family history
of addiction, attending any workshop before, and potential for
addiction post-intervention at P˂ 0.01. At p-values=(0.825,
0.795, 0.105, and 0.825), there was no significant

Table 7: Relation between potential for addiction and socio-demographic characteristics of the studied patients.

Studied Variables Pre Post T-value P-value R-value P-value

Mean S.D. Mean S.D.

Age Less than 82.68 10.98 48.86 5.99 24.04 0 0.76 0

40

More than 80.36 14.03 42.63 5.69 8.26 0 -0.08 0.825

40

Place of Rural 84.97 11.06 49.34 7.26 14.92 0 0.45 0.013

living
Urban 81.18 11.34 47.51 5.72 20.72 0 0.74 0

Marital Single 84.67 9.86 50.76 5.34 17.37 0 0.81 0

status
Married 81.06 10.36 48.14 5.07 17.13 0 0.63 0

Widowed 84.43 16.58 40.86 6.23 6.51 0 0.12 0.795

Divorced 79.5 13.92 45.36 7.6 8.05 0 0.86 0

Occupation Worked 82.07 11.05 47.74 6.34 22.38 0 0.55 0

Not 83.86 12.24 49.55 6.01 11.81 0 0.91 0

worked

Educational High 82.76 10.92 49.29 5.42 16.92 0 0.87 0

level education

Secondary 87.14 7.71 51.36 4.74 20.93 0 0.51 0.006

Read and 72.85 11.42 42.23 5.45 8.73 0 0.47 0.105

write

Illiterate 80.36 14.03 42.64 5.69 8.26 0 -0.08 0.825

Attending Yes 83.22 10.93 48.38 6.62 21.81 0 0.55 0

any
workshop No 80.38 12.22 47.42 5.39 12.57 0 0.87 0
before

Income Sufficient 78.67 12.16 44.81 6.12 17.23 0 0.51 0

Insufficient 86.87 8.61 51.86 3.92 23.85 0 0.71 0

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Khalil AI, et al.

Family Positive 83.48 10.19 49.53 5.39 22.8 0 0.72 0

history of
addiction Negative 80.23 13.23 45.23 6.98 12.81 0 0.51 0

Table 8 shows there was a highly statistically significant illiterate. There was no significant relationship between
relationship between all socio-demographic characteristics of them and the assertion in drug use post-intervention at p-
studied patients (age less than 40, the residence of value=(0.477, 0.863, and 0.477) respectively.
the participants, marital status, income, family history
of addiction, and attendance at any workshop before and
after the assertion in drug use post-intervention at P-
value=(0.01) except age more than 40, widowed, and

Table 8: Relation between assertion in drug use and socio-demographic characteristics of the participated patients.
Studied variables Pre Post T-value P-value R-value P-value

Mean S.D. Mean S.D.

Age Less than 79.62 8.67 128.27 8.59 35.42 0 0.77 0

40
More than 78.45 4.69 124.64 4.72 23.01 0 -0.24 0.477
40
Place of Rural 73.24 8.18 121.45 9.69 20.48 0 0.75 0
living
Urban 82.44 6.52 130.85 5.4 44.65 0 0.51 0
Marital Single 77.45 9.23 127.18 8.81 22.39 0 0.82 0
status
Married 79.94 8.45 128.78 8.88 23.9 0 0.74 0
Widowed 76.86 5.27 126 5.48 17.1 0 -0.08 0.863
Divorced 84.36 3.61 127.79 6.94 20.77 0 0.89 0
Occupation Worked 79.81 8.21 127.84 8.24 34.31 0 0.64 0
Not 77.68 9.01 126.82 9.55 17.56 0 0.86 0
worked
Educational High 81.11 6.87 130.21 6.46 32.13 0 0.43 0
level education
Secondary 76.46 11.12 124.75 11.51 15.97 0 0.91 0
Read and 82.08 5.29 130.15 3.05 28.35 0 0.59 0.035
write
Illiterate 78.45 4.69 124.64 4.72 23.01 0 -0.24 0.477
Attending Yes 79.52 8.99 126.03 8.85 29.5 0 0.79 0
any
workshop No 79.38 6.33 132.23 4.34 35.1 0 0.76 0
before
Income Sufficient 82.35 6.08 129.69 5.36 40.49 0 0.55 0
Insufficient 76.19 9.25 125.69 10.37 23.09 0 0.78 0
Family Positive 78.9 8.6 126.03 9.21 28.97 0 0.79 0
history of
addiction Negative 80.63 7.58 131.8 4.29 31.92 0 0.62 0

Table 9 shows there was a highly statistically
significant relationship between age less than 40, the
residence of the participants, marital status, occupation,
income, family history of addiction, attending any
workshop before and the quality of relationships post-
intervention at P-value=(0.01). While there was no
significant relationship between age over 40, widowed,
read and write, and illiterate and post-intervention
relationship quality at p-values o f ( 0.194, 0 .444, 0 .250, and
0.194).

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Khalil AI, et al.

Table 9: Relation between quality of relationships and socio-demographic characteristics of the participated patients N=90.
Studied variables Pre Post T-value P-value R-value P-value
Mean S.D. Mean S.D.

Age Less than 41.14 8.57 82.85 8.02 31.58 0 0.63 0

40
More than 49 5.39 84.63 4.82 16.23 0 0.424 0.194
40
Place of Rural 39.89 10.73 81.34 6.37 17.89 0 0.79 0
living
Urban 43.15 7.28 83.84 8.19 29.01 0 0.53 0
Marital Single 37.76 8.21 83.21 7.03 24.15 0 0.83 0
status
Married 43.38 7.42 85.06 5.94 26.32 0 0.79 0
Widowed 49 6.51 84.29 5.88 10.65 0 0.35 0.444
Divorced 45.57 9.16 76.79 10.91 8.19 0 0.71 0.004
Occupation Worked 42.77 8.55 82.78 7.76 28.79 0 0.69 0
Not 39.27 8.97 83.36 7.81 17.39 0 0.61 0
worked
Educational High 44.84 7.27 85.66 5.65 27.34 0 0.64 0
level education
Secondary 35.25 8.63 80 8.12 19.99 0 0.73 0
Read and 43 4.32 80.77 11.11 11.42 0 0.34 0.25
write
Illiterate 49 5.39 84.36 4.82 16.23 0 0.42 0.194
Attending Yes 41.86 9.49 81.43 7.83 25.72 0 0.61 0
any
workshop No 42.69 6.06 87 5.82 26.88 0 0.77 0
before
Income Sufficient 44.65 6.75 83.5 8.21 25.32 0 0.42 0
Insufficient 39.19 9.63 82.5 7.13 23.42 0 0.84 0
Family Positive 41.6 9.92 83.27 6.86 26.76 0 0.67 0
history of
addiction Negative 43.1 5.12 82.57 9.27 20.41 0 0.65 0

Figure 4 revealed that there was a highly level of assertiveness skills in drug use post-intervention
statistically significant reduction in the level of potential for compared to 3.33% pre-intervention.
addiction post-intervention compared to pre-intervention
where 16.67% of the participants had a high level of
potential for addiction post-intervention compared to 84.4%
pre intervention.

Figure 5: levels of assertion in drug use among the studied

Figure 4: levels of potential for addiction among the studied
patients' pre- and post-Intervention.
Figure 5 sillustrated that there was a highly
statistically significant improvement in the level of
assertiveness skills in drug use post-intervention compared to
pre-intervention, where 85.56% of the participants had a high
patients’ pre and post-intervention (N= 90).
DISCUSSION
Drug abuse is not affected only every part of the abuser's life
as social life, family life, work productivity, bodily health, and
individual relationships but also affected all aspects of the
community. Drug abusers are experiencing problems related

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Page 13
to non-assertive and aggressive behaviors. Assertiveness
training is a central component affecting the continuous
sobering behavior among drug abusers and relapse
prevention and recovery. Assertion training appears to be a
productive drug abuse prevention strategy. The role of
assertion training as a drug abuse prevention strategy is
restricted to that fostering the competence to say "no" in
peer pressure situations focused on drug use.
CONCLUSIONS
The study showed that the most common types of addiction
among participants were heroin and multiple types.
Assertiveness training in this study positively affected the
reduction of drug use tendency. It can play a significant role in
the design and implementation of drug abuse prevention
training programs. There was a significant improvement in the
level of assertiveness skills for drug addicts’ post-intervention
compared to pre-intervention, with 85.56% of participants
having a high level of assertiveness skills post-intervention.
This indicates the efficiency of the assertiveness training
program in continuous sobering behavior among drug
abusers. Moreover, the participants were satisfied as their
goals and expectations were met during the training program.
Therefore, the following is highly recommended:
• Assertiveness skills training programs must be
disseminated to all psychiatric hospitals and addiction
treatment centers in Egypt.
• Assertiveness training for nurses should be ongoing in
order to detect, prevent and treat drug abuse as early as
possible.
• Communities that make an effort to come together in the
fight against drugs are sure to make an impact on the
prevention of drug abuse.
• Implementing the prevention and assertiveness program
in many other places, including schools, churches and
community based clubs.
Implications for Nursing Practice and Management
Great attention should be paid by society to reducing the drug
abuse of its citizens. There is a need for close collaboration
between schools and the community in addressing drug
abuse. Parents and family members should thus play an
effective role in reducing drug abuse among their children.
The ministry of primary and secondary education must
formalize and support the establishment of a vibrant guidance
and counseling system in schools. Design appropriate
assertiveness skills training to enhance life skills training and
should be applied in drug rehabilitation centers along with
detoxification treatments to improve self-esteem and
assertiveness and maintain sobriety. Assertiveness skills
training should be given to psychiatric and community nurses
in different psychiatric and mental health settings. A high
premium should be placed on developing and mainstreaming
prevention programs on drug abuse into the school
curriculum for students to become more assertive and
acquire more knowledge about drugs and their effects and
Khalil AI, et al.
complications on mental health. In the end, it is suggested
that some steps should be taken toward enhancing the
awareness of people and reducing their drug use tendencies
by holding assertiveness skills training workshops for them.
Further longitudinal research studies should be carried out to
assess the causes and cultural factors that significantly affect
addiction and drug abuse. Further studies in different settings
are to be conducted, such as schools, factories, other colleges,
and institutions all over the Arab Republic of Egypt to increase
awareness about the complications and dangers of drug
abuse.
LIMITATIONS OF THIS STUDY
Because of the small sample size and the absence of a control
group, the findings cannot be generalized to the population of
drug users. Furthermore, no follow-up was performed in the
current study to confirm whether the program was effective
or not to maintain sober behavior among studied participants.
ETHICAL CONSIDERATIONS
Permission to conduct the study was obtained from the
ethical and research committee of the Faculty of Nursing,
Menoufia University, who sent an official letter to the
Egyptian general secretariat of mental health to receive their
approval to conduct the study at the psychiatric and addiction
treatment hospital in Meet-Khalaf, affiliated to Menoufia
Governorate, Egypt. After official approval was obtained, the
letter was sent to the director of the selected setting to send
the approval to conduct the study. The purpose of the study
was explained to all participants and an informed letter of
consent was received. Along with an emphasis on
confidentiality and anonymity of information, participants
were informed that they would be free to withdraw from the
study at any time during the study.
ACKNOWLEDGEMENT
The authors would like to express their gratitude to the study
participants, all nurses, and the administration of MEET-Khalaf
hospital, who collaborated and contributed to this study.
CONFLICT OF INTEREST
The authors declared that they have no conflict of interest.
AUTHOR CONTRIBUTIONS:
• Prof. Amal Khalil: Initiated the idea of the research and
design; wrote the background, methodology, and data
collection procedure; prepared the assertiveness training
program; did a review of the whole manuscript (editing
and paraphrasing); and formatted the manuscript for
publication submission.
• Dr. Safaa Shatalah: Collected data, shared in preparing the
contents of the program, conducted the training with the
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Page 14
patient in the hospital setting, and added comments to
tables.
• Dr. Eman Shoker: Wrote the discussion, conclusion and
recommendations.
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